Wednesday, June 07, 2017

Weight loss is the easy part

In the spring of 2014, I met with my doctor for a regular physical. My doctor's always been really supportive, but sometimes I think he's only impressed by me because his other patients are pretty old. He'd say things like: "Your chloresterol levels are really good. I have patients on statins whose chloresterol levels aren't this good." My first thought was: "well, if their chloresterol levels were good, you wouldn't have had them on statins anyway!"

This time, however, the news wasn't good. My fasting blood sugar levels were elevated. Rather than do a re-test, he said, I should get an a1c test. He thought the a1c level is a much more reliable indicator of diabetes risk. My a1c level came in at 5.9%, which was pre-diabetic. "What does this mean, doc?" "It means if you don't do anything about it, you'll get diabetes within 10 years." "I definitely don't want that!" "Let me refer you to a nutritionist. You're one of the few people to whom I can't say 'exercise more' to, but in many cases if you lose a bit of weight that should be enough to prevent diabetes."

I made an appointment with a nutritionist, and she had me do a food diary for a week prior to the appointment. For a week, I weighed everything I ate. My doctor's comments had scared me into eliminating sweets and desserts from my diet. It was ironic that just as I'd finally had the time, know-how, and equipment to make a really good creme brulee (and I'd gotten pretty good), I could no longer eat one. I e-mailed the spreadsheet to the nutritionist prior to the appointment, so by the time I showed up she had everything calculated: I was eating too much.

My weight was 155 pounds, and at 5' 10", that gave me a normal BMI of 22.2. But with a family history of diabetes (both my parents had it, though my mom could control hers mostly through diet and exercise), clearly my heritage meant a greater susceptibility to metabolic syndrome than the average American. As they say, "Life isn't fair. It's just fairer than death." I graduated college at 113 pounds, and in 2003 weighed around 130 pounds, so I thought I had a good chance of getting down to at least 145 pounds.

Weight loss is fairly straightforward: eat less than you burn. The nutritionist had me cut down portions on calorie dense foods. "A fistful of rice or pasta is one serving." Similarly, a handful of nuts was all that you wanted. We went through my entire day's diet and basically cut down serving sizes everywhere. She emphasized eating more vegetables. I determined to switch to having salad prior to eating other entrees. (The alternative was soup, but unless I'm at Hotel Rosenlaui, I don't usually like soup)

The nutritionist also explained what the a1c test is: it measures how much of your blood hemoglobin has been glycated (i.e., been coated with sugar). The higher the a1c level, the more of your hemoglobin's been coated with sugar, indicating that you've had more frequent bouts of increased blood sugar. The reason it's considered a better test for diabetes by my doctor is that red blood cells on average live for 3 months, so it's less prone to day to day fluctuations from dehydration, exercise, etc. As a bonus, you also don't need to fast prior to getting the a1c test.

Actually putting the diet into practice was eye-opening. What it did was to re-calibrate me on what was the proper amount. Prior to it, I was eating until I was full. I learned that you can't do that once you're in your 40s. You need to eat until you're about 75% full (unless you're bicycle touring, at which point your problem is eating enough to stay fueled). Once I'd recalibrated my stomach and sense of fullness, the weigh loss came easily. I quickly went down to 145 pounds by the time of the 2014 Tour of the Alps.

I'd once thought that my optimum weight was 145 pounds, because weight loss below that during the Tour Across France caused me no small amount of performance loss. But what happens in your 30s doesn't always happens in your 40s. During the tour, I reduced my weight to 140 pounds. After the tour, I made sure to reduce my food intake back to normal, and my weight loss continued. My nutritionist was worried that I was losing too much weight, but I assured her that I wasn't waking up in the middle of the night hungry.

Very disappointingly, getting my weight down to 135 pounds didn't have a dramatic effect on my a1c levels. It went down to 5.8. "That's a good trendline," my doctor said, but I was used to having much more impact through lifestyle changes, especially considering that my body weight loss was much more than the 7 pounds the doctor originally said would be sufficient.

One thing I never realized until I started doing it is how much Chinese culture would rather that you be fat. This probably isn't just restricted to the Chinese, since even in English, the opposite of "Fat and Happy" is "Lean and Mean." But person after person would comment on my weight loss, usually with negative connotations. My mom started asking me if I was healthy because I'd lost so much weight. I even have a memory of watching (with my wife) the Chinese version of "The Bachelor" TV show where one woman explicitly laid out her need for a guy with a paunch as one of her key requirements! Fortunately, as a cyclist, I'm used to society's negative associations with my favorite sport, so I pretty much ignored all the peer pressure and went ahead with my weight loss.

I wish I could tell you that there was a break through, or a magic pill. To be honest, I wasn't interested in doing science experiments: I just wanted to get that a1c level down. So I tried a bunch of stuff including increasing my coffee intake to 3-5 cups of coffee per day (to prevent the jitters, about half that intake was decaf). I didn't put salad dressing on my salad, preferring to add seeds and nuts to it (much of the nutrition from salad is fat-soluble, so to get the most out of it you do need some fat in the salad). I had my sleep apnea under my control, but I could also change my exercise regiment, to add more intervals to it, and to cross-train with swimming so that I could up the intensity when I did get on the bike. I added a fitness tracker to my wrist. My 2016 Tour of the Alps was one of the toughest challenges ever, and I felt better than ever by the end of the tour. My weight went down to 130 pounds and then down to about 125 pounds. I now look back at pictures of myself from 2012-2013 and exclaim, "Holy crap I was fat!" My wife said she hadn't noticed because when she met me I was already fat. This goes to show that you gain weight slowly, so you'll never actually know that you're fat unless you actively weigh yourself.

All through the past 3 years, I'd get my a1c levels checked every 6 months or so. My doctor (who was astounded at how quickly I could take off weight) was always encouraging, even when the levels ticked up. "Keep doing what you've been doing." Finally, this year's test came out of the pre-diabetic range. I'm now no longer pre-diabetic! Of course, there's always a margin of error on tests, so I can't ease up on the lifestyle changes. But the nice thing about lifestyle changes are that if you do them right, they're sustainable for the long term --- I no longer get the urge to eat dessert. This has been by far the toughest health project I've done so far, but it's a relief to know that I'm actually finally getting some results. The long feedback cycle (it makes no sense to test a1c more than once every 6 months) and the long delay in the changes taking effect explain why fighting diabetes is so challenging. By comparison, weight loss was the easy part.
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